After Hours

Well I’ve just received a letter from the Federal Health Minister which seems to broadly confirm my suspicions that the charging of fees for country patients attending a public hospital ED is incorrect.

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Of course there is a grey area in what is a ‘GP after hours’ type attendance and what is an emergency attendance – and with that comes the potential for massive cost-shifting from the State (charged with providing free public emergency treatment) and the Commonwealth (providing Medicare compensable services).

Country patients are caught up in this, as in South Australia they have been charged fees for attending the ED in rural hospitals. Now historically there was an arrangement (not defined in a contract, but in an agreed schedule of fees for paying doctors called SARMFA) that allowed a rural doctor to charge a private fee in circumstances where a patient requested private treatment by a particular doctor, or where care was provided in the country hospital as part of ongoing care or prior arrangement.

This seems a sensible compromise to allow rural doctors to attend patients at the hospital both in and after hours for GP-type consultations or private care. Example might be an agreement between doctor and patient to meet at the hospital after routine consulting for a review of an eye injury, utilising the hospital’s slit-lamp. or arranging to be seen for a skin excision or to administer intravenous therapy.

All well and good.

Then in 2010 a new contract (in fact the first time a written arrangement about rights & responsibilities) between CHSA and rural doctors came into being. This is a good thing and it was hoped that would create a level-playing field with rural doctors getting equivalent deals, rather than the hotch-potch of ‘local deals’ that saw some doctors getting lucrative locum rates for being oncall, others struggling to balance the impact of providing oncall work for the hospital with their private practice.

The negotiating teams of both AMA and RDASA invested a lot of time and effort into getting the ‘best deal’, but as time wore on the AMA walked away from the offer whilst the RDASA recommended to their members on a temporary basis, expecting a new and better deal to be negotiated by the end of November 2011.

My concern has been that, for the first time, there is a contract that is explicit about the charging of fees. Whilst the SA Health Minister acknowledges that CHSA are responsible for the provision of public emergency services in the country, there is a catch. The contract specifies that only ADMITTED patients are entitled to free treatment – non-admitted patients are to be charged by the attending doctor.

This seems to fudge the previous arrangement designed for private services or ongoing care between patient and treating doctor. Instead, people who present to a rural ED in South Australia are charged fees unless they are admitted….and yet patients with similar problems who go to a metro ED are provided the service for free.

The Health Minister says this is because rural hospitals do not have a salaried medical officer on site. Fair enough. I’d just argue that if the Hospital feels they need to call in a doctor, that that doctor is paid for their services – and the patient does not.

Of course, if the patient presentation is trivial (a GP-type attendance) then it would be appropriate to divert them to a GP-after hours service or to GP clinic the next day – and Medicare or private fees would apply.

It’s all down to definition. What is an admitted patient? The bean-counters take the view that a patient has to be present for > 4 hours, although occasionally this requirement can be relaxed for certain things (type C attendances, a definition derived from mostly day surgery units).

So we have a position now enshrined in a contract, where rural patients may be charged for things like reduction of a fracture, IV fluids, X-rays, assessment after a car crash, mental health emergency in a country ED…on the basis that these are ‘GP services’. These are things that a GP in the city may well refer patients to an ED for.

Medicare advisors tell me this is illegal and that doctors should not charge for such non-admitted ED services where patients attend a public ED. The Dept of Health & Ageing letter suggests the same.

The only explanation from CHSA is that this is allowed because of a ‘longstanding arrangement for treatment of private patients as part of ongoing care or prior arrangement by a specific doctor’.

I am all for this – when such care is agreed and is genuinely private. I have no qualms charging a private fee for my private GP services.

Seems hard to explain that all this to the carload of NSW tourists who have crashed and seek assistance at the local hospital only to be saddled with a bill. Or the patient with a fracture-dislocation that requires X-ray/reduction/plastering…and many more examples. Understandably some patients refuse to pay on the basis that they are attending an ED. CHSA insists that the doctor charges Medicare..who say that this practice is illegal…and CHSA doesn’t answer this query.

So, where are we at now?

There have been two extensions to the rural doctors contract (which was to expire 30/11/11) so far…the current extension ends in just under four weeks and still no contract offer available for perusal.

In an effort to address this anomaly, RDASA had proposed that triage 1-2-3 patients are to receive free treatment. Seems fair, although it does ignore the issue that triage is just about treatment priority, not complexity and is ill-suited to decisions about whether ED attendance is appropriate or not. There is a myth that triage 4/5 patients are ‘GP-type’ presentations, when in fact these patients are often elderly, complex and require admission or the services of an ED not a GP (minor fractures, plastering, X-ray etc). ACEM have issued a media release on this which is informative.

– A contract that seems to be in breach of the National Healthcare Agreement.– Cost-shifting fees onto patients who are already rurally disadvantaged. – And only a few weeks to go until the most recent contract negotiation expires.

Really, is this any way to do business? It seems that Country Health SA hold both rural patients and the medical workforce with a lack of respect. I despair, because this sort of thing does little to encourage recruitment and retention of rural doctors to South Australia.

Tim Leeuwenburg

RESUSCITATE - DIFFERENTIATE - INVESTIGATE

I am a Rural Doctor on Kangaroo Island, South Australia with interests in emergency medicine, anaesthetics & trauma. When not working I enjoy fiddling with chainsaws and seakayaking. Along with partner Patricia we rehabilitate orphaned wildlife and devise roadkill recipes.